What are the guidelines for proper chest tube care?

Guidelines for Proper Chest Tube Care

Small-bore chest tubes (10-14F) should be used initially for most pneumothoraces, with larger tubes only considered when there is persistent air leak or pleural fluid present. 1

Insertion and Securing Techniques

• Chest tubes should never be inserted using substantial force or trocars, as this risks damage to intrathoracic structures 1
• After insertion, a chest radiograph must be performed to check tube position and ensure a pneumothorax has not developed 1
• The chest tube incision should be closed by a non-absorbable suture to narrow the linear incision around the edge of the chest tube 1
• Drains must be well secured after insertion using either a stay suture criss-crossed up the drain, special dressings/fixation devices, or steristrips with transparent adhesive dressing 1
• Extra care must be taken when placing chest tubes to avoid open communication with the pleural space and potential emission of droplets and aerosols 1

Drainage System Management

• All chest tubes should be connected to a unidirectional flow drainage system (such as an underwater seal bottle) which must be kept below the level of the patient's chest at all times 1
• The underwater seal bottle should have a side vent which either allows escape of air or is connected to a suction pump 1
• Whenever possible, use non-wired pleural drainage connected to the drainage system before insertion into the pleural cavity (closed circuit) 1
• In case of prolonged air-leaks, wall suction should be considered to create a closed system 1
• Maintenance of chest tube patency without breaking the sterile field is recommended to prevent retained blood complications 1

Pain Management

• Intrapleural local anesthetic (20–25 ml of 1% lignocaine) given as a bolus and at eight-hourly intervals after chest tube insertion significantly reduces pain without affecting blood gas measurements 2
• Intercostal nerve blocks provide effective analgesia for chest tube-associated pain when pharmacological management is inadequate 2
• NSAIDs should be used as the primary systemic analgesic for chest wall pain due to their proven efficacy 2

Important Safety Considerations

• A bubbling chest tube should never be clamped, as this could potentially convert a simple pneumothorax into a life-threatening tension pneumothorax 1
• A chest tube which is not bubbling should not usually be clamped 1
• If a chest tube is clamped (which should be rare), this should only be done under the supervision of a respiratory physician or thoracic surgeon, with the patient managed in a specialist ward with experienced nursing staff 1
• If a patient with a clamped drain becomes breathless or develops subcutaneous emphysema, the drain must be immediately unclamped and medical advice sought 1
• Full aseptic technique must be used during insertion or manipulation of any chest drainage system to prevent infection, as the rate of empyema after chest tube insertion has been estimated at 1-6% 1

Monitoring and Complications

• Respiratory swing in the fluid level of the chest tube is useful for assessing tube patency and confirms position in the pleural cavity 1
• Watch for development of surgical emphysema, which may occur with malpositioned, kinked, blocked, or clamped tubes 1
• Active chest tube clearance methods can be used to prevent occlusion without breaking the sterile field, which has been shown to reduce the need for interventions to treat retained blood 1
• Stripping or breaking the sterile field of chest tubes to remove clot is not recommended 1

Referral Guidelines

• Pneumothoraces which fail to respond within 48 hours to treatment should be referred to a respiratory physician 1
• Failure of a pneumothorax to re-expand or a persistent air leak exceeding 48 hours duration should prompt referral to a respiratory specialist 1

By following these evidence-based guidelines for chest tube care, clinicians can minimize complications and optimize patient outcomes while managing pleural conditions requiring drainage.